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The use of uterine artery Doppler

in pregnancy induced hypertensivedisorders

Daiva Simanaviciute, MD Kaunas University of

Medicine, Department of Obstetrics and Gynaecology,

LITHUANIA

Tutor: Eric Antonelli, MD, Geneva University Hospital,

Department of Obstetrics and Gynaecology,

SWITZERLAND

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Doppler ultrasound: basic

principlesUltrasound images of

flow (color or spectral

Doppler), are essentially

obtained frommeasurements of

movement.

The ultrasound scanner

transmits a series of pulses

to detect

movement of blood.

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Doppler velocity measurements

Echoes from stationary

tissues are the same from

pulse to pulse. Echoes frommoving objects exhibit

slight differences in the time

for the signal to be

returned to the receiver.

These differences can be

measured as a direct time

difference or, more

usually, in terms of phaseshift from which the

Doppler frequency is

obtained. As bloodvelocity

increases, so does the

Doppler frequency.

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The effect of the Doppler angle

in the sonogram A higher-frequency Doppler signal

is obtained if the beam is alignedmore to the direction of flow.

In the diagram, the beam A is more

aligned than beam B and produceshigher-frequency Doppler signals.

The beam/flow angle C is almost 90and there is a very poor Doppler

signal.

The flow D is away from the beamand there is negative signal.

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Doppler ultrasound: basic

principles

The time difference

or phase shift are

then proceeded toproduce either color

flow display or a

Doppler sonogram

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The possible Doppler

velocimetry sites

Umbilical arteryin cases of fetal

growth restrictionand other cases

with non-

reassuring fetal

heart rate.

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The possible Doppler

velocimetry sites

Middle cerebral

artery in cases offetal growth

restriction or for

anaemia

detection.

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The possible Doppler

velocimetry sites

The detection of

congenital fetalheart anomalies

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The possible Doppler

velocimetry sites

There is also a possibility to evaluate bloodflow in fetal renal artery in cases of

intrauterine fetal growth restriction(IUGR),

lienal artery (in cases of Rhalloimmunisation for Hb level evaluation),

in thefetal veins (V. cava, umbilical V.,venous ductus) in cases of IUGR, and in

pulmonary veins (for pulmonary status

evaluation)

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The flow velocimetry waveforms of the

uterine artery (normal waveform)

For prediction of pre-

eclampsia and fetal

intrauterine growth

restriction in the first andsecond trimester of

pregnancy;

For the differential

diagnosis of the causes of

fetal intrauterine growthretardation.

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The technique of uterine artery

Doppler

The Doppler velocimetrymeasurements of the

uterine artery are taken

at the point just distally

to the crossover with the

iliac artery, beforeuterine artery division

into arcuate arteries.

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Changes in uterine blood flow in

normal pregnancy (1)

Placental trophoblastic invasion into themyometrium has profound effect on the

uterine circulation.

It happens by means of changing of the

lay-muscular tissue by endovascular

throphoblast in spiral arteries wall. As a result these arteries loose the

possibility to react to endogenousvasoconstrictive agents.

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Changes in uterine blood flow in

normal pregnancy (2)

The blood flow in it changes from one of low

flow and high resistance to one of high flow and

low resistance latest until 24 weeks of pregnancy.

The uterine artery represents the wholeuteroplacental blood flow.

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Abnormal uterine artery Doppler

waveforms(low diastolic flow andprotodiastolic notch)

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Doppler velocimetry indices

A/B= (the systolic/diastolic ratio) is calculated by measuringthe systolic peak and the end-diastolic flow.

A/C= (systolic proto-diastolic ratio) is used to evaluate thedepth of the proto-diastolic notch.

RI= Peak systolic flow (A)-least diastolic flow (B)Peak systolic flow (A)

PI= Peak systolic flow (A)-least diastolic flow (B)Mean blood flow velocity

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The reason for early pre-

eclampsia screening

The possibility to distinguish the high riskpregnancies (with abnormal uterine artery

Doppler velocimetry results and history of

impaired placentation) would let to modifythe follow-up

and to try preventive treatment regimens(low-dose aspirin, low-molecular weight

heparin or antioxidants).

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Pre-eclampsia screening in the

first trimester of pregnancy

The combined use of transvaginalultrasonography with the pulse-color

Doppler technique allows the study of theuterine and umbilical circulation during

the first trimester.

Color Doppler imaging helps to identify the

changes in uterine artery blood flow at

6-9 weeks of gestation.

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Doppler velocimetry use for pre-eclampsia

screening in the early pregnancy

Arduini D. et al. (1991) examined 330 low-risk pregnancies recruitedfrom the outpatient division at 7-16 weeks of gestation

Elzen et al. (1995) measuredpulsatility index (PI) values at 12-13 weeks in

a prospective cohort study of352 women aged 35 years or older.

Harrington K. et al. (1997) carried out a follow-up study in 652women with singleton pregnancies who had transvaginal uterine and

umbilical artery Doppler examinations performed at 12-16 weeks'gestation.

Uzan M. (6th annual meeting in fetal medicine, that was held 29 March - 1

April, 2001) presented the data of the two years study of uterine arteryDoppler performed at 12 weeks of gestation

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The Results of the studies

Arduini D. et al. (1991)no evident differences were

found in arteries (uterine,arcuate or trophoblastic)

between patients with later

complications and those with

normal pregnancy. Uzan M. et al.(2001)

concluded that normal uterine

artery Doppler FVWs in early

pregnancy allowed todistinguish the group of

pregnancies with very low risk

to develop pregnancy vascular

complications.

Elzen et al. (1995) found asignificant associationbetween

uterine artery PI values(comparing lowest and highest

quartile) at 12-13 weeks and

hypertensive disorders (RR=4)

Harrington K. et al.

(1997) values from women

with a normal pregnancyoutcome, differ significantly

from women who subsequently

developed PPIH (mean RI =

0.80 vs.. 0.695, p < 0.001).

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Pre-eclampsia screening in the

second trimester of pregnancy

More than 30 publications reported onthe pre-eclampsia screening in the second

trimester of pregnancy

in high risk pregnancies and in unselected population

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Comprehensive comparison of all previously

published methods

Aquilina J. et al. (2000) examined 614 primiparous women by colorflow/pulse Doppler imaging of both uterine arteries at 20 weeks gestation.Receiver operator characteristic (ROC) curves were created for the A/B ratio,

RI and A/C ratio for placental and non-placental uterine arteries,

individually or in combination with the presence of unilateral or bilateral

notches.

The highest sensitivity (88%) and specificity of (83%) was obtained using

bilateral notches/mean RI > 0.55 (50th centile) and unilateral notches/mean RI

> 0.65 (80th centile), when the false-positive rate was set at 17%.

Placental velocimetric indices performed better than mean indices but the

differences in sensitivity at the set false-positive rates were not statistically

significant.

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The best sensitivity and PPV by the apex of

the ROC curves

Sens. (%) Spec. (%) PPV (%) OR (95%CI)

Any notch plus mean

A/B ratio >/=2,64

8 83 26 14,6(6,9-

30,9)

Billateral notchesA/C ratio >/=2,1

86 83 28 31,0(11 6-82,3)

Billateral notches

plus mean RI>/=0,55

88 83 28 33,1(12,6-

86,9)

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Receiver operator characteristic

curves for methods using RI mean RI (diamonds)

mean RI plus any notch (open

circles)

placental RI (closed circles)

placental RI ratio plus any

notch (stars)

bilateral notches plus mean RI

(triangles).

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Pre-eclampsia probability changes

using Doppler velocimetry (Chien F. etal. systematic review 2000)

A bnorm al tes t

results

N orm al test resu lts

Low r isk p regnancies

3 ,5 (95% CI 3 ,1-3,9) to 1 8,8

95% C I 16,4-21,5

3,5(95% C I 3,1-3,9)to 2 ,5 (95% C I2,1-

2,9)

H igh r isk

p regnancies

9,8 (95% C I7,9-

11 ,8) to 23,5

(95%CI18,6-29,2)

9 ,8 (95% CI7,9-

11,8) to 7 ,8(95% C I

6,1-10,0)

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Conclusions Increased impedance to flow in the uterine

arteries in both high-risk and low-riskpregnancies is associated with increased risk of

development of pre-eclampsia and intrauterine

growth restriction.

Women with normal impedance to flow in theuterine arteries constitute a group that have a

low risk of developing obstetric complications

related to uteroplacental insufficiency.

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Conclusions Increased impedance to flow in the uterine

arteries in pregnancy attending for routineantenatal care identifies about 50% of those

that subsequently develop pre-eclampsia.

Abnormal Doppler is better in predicting

severe rather than mild pre-eclampsia. The

sensitivity for severe pre-eclampsia is about

75%.

Wh t ti i t b

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What questions remain to be

answered? Very early screening ??

For what ??

Aspirin or other preventive treatment ??

What kind of studies to be done??